How To Manage The Complication of

ACS Patients
Suryono
6th Surabaya Cardiology Update
Surabaya, Saturday 12th September 2015

Complications in Acute Coronary Syndromes

ACS complication includes :
1. Conduction diturbances
2. Hemodynamic disturbances
3. Mechanical complication

1. Conduction Disturbances
Sinus Bradycardia
Sinus Tachycardia
Atrial Fibrillation
Ventricular Arrhythmias
Heart Block

Sinus Bradycardia
Occurs in 15-25% of AMI, usually inferior wall or RV
Usually transient and resolves within 24 hours
Caused by increased vagal tone, SA node ischaemia,

drugs (BB), reperfusion after fibrinolysis

Treatment :
1. Atropine
2. Temporary pacing

Sinus Tachycardia
Occurs in 30-40% of AMI
Persistent tachycardia more common with larger

MI and anterior MI
Associated with higher morbidity and mortality
Treatment :
Beta Blocker

Atrial Fibrillation
Incidence 5-18%

Usually associated with comorbidities : heart failure,

kidney diseases, hypertension, diabetes, pulmonary

diseases
Treatment :
1. Rate control with BB
2. Amiodarone

Ventricular arrhythmias in STEMI (all

locations) :
Non Sustained VT (<30 seconds) :
No treatment unless frequent and symptomatic :
BB, Amiodarone, Procainamide
Sustained Monomorphic VT (>30 seconds)
with hemodynamic symptom :
Usually transient, Due to ischaemia in first 48
hours of AMI
Cardioversion, Amiodarone, Procainamide,
Lidocaine
,

VF :
Usually occurs in 48-72 hours after MI
The persence of ST elevation is the most powerful predictor of
VF
Other predictors : early repolarization, hypokalemia,
hypotension, higher troponins, severe LV dysfunction
Associated with higher in-hospital mortality
Treatment : Defibrillate, Amiodarone, Reperfusion
ICD have been shown to reduce mortality in
post MI pts with EF 30%

Heart Block of MI
Inferior Wall MI :
1st degree and Weckenbach occur in the AV node and usually due

to RCA occlusion. Usually resolves within 5-7 days. Usually it

requires no treatment.
Anterior Wall MI :
More serious block that occurs below the AV node with wide
QRS
Second Degree type 2 and Third Degree more common
High mortality rate : 80%
Tx : Temporary pacing

2. Hemodynamic Disturbances :
Cardiogenic Shock
Causes :

Extensive LV infarction
Mechanical complication
Mortality rate : 80-90%
The larger the infarct the more pump failure occurs

 Management of Cardiogenic Shock

(ACC/AHA Guidelines) :
Emergency revascularization with either PCI or CABG

for cardiogenic shock due to pump failure after STEMI

(Class Ib)
Immediate transfer to a PCI-capable facility with onesite cardiac surgical back up is indicated for patients
with STEMI and CS
Fibrinolytic therapy for patients without
contraindication and when revascularization is not
feasible

Usual medical treatment of STEMI except Beta

Blocker
Inotropic and vassopressor support
IABP (Class IIa)
Especially for RVMI : volume load & avoid diuretic to
keep PWP optimal (usually around 18 mmHg)

Right Ventricular Infarction :

40% incidence with inferior MI :

- Most often proximal RCA occlusion

- Higher mortality when RV infarcted
Pathophysiology of RVMI :
Decreased right ventricular compliance
Reduced RV filling
Decreased RV stroke volume

Decreased LV filling Periferal hypoperfusion : hypotension,

tachycardia

Right Ventricular Infarction :

Diagnosis : clinical triad of Hypotension, Elevated JVP,

Clear lung fields (decreased PWP)

Get right side chest lead (V4R V6R) with all inferior wall MI
Treatment :
Fluid to increase LV filling
Avoid preload reduction (Nitrat, diuretic)
Inotropes (Dobutamine, Dopamine)
Maintain atrial kick (Cardioversion of AF may be needed)
Temporary pacing if bradycardia

3. Mechanical Complication :
Papillary Muscle Rupture Acute Mitral

Regurgitation
Ventricular Septal Rupture
Ventricular Free Wall Rupture
Cardiac Tamponade
Ventricular Aneurysm
Thromboembolism
Acute Right to Left Shunt Through Foramen
Ovale

Papillary Muscle Rupture

Life threathening
It causes Acute Mitral regurgitation

More common in inferior MI

Occurs 2-7 days after MI
Present with : hypotension, acute dyspneu, heart failure

pulmonary edema, new systolic murmur

Diagnosis by : Cardiac echo (TEE or TTE)
Management :
Afterload reduction : Nitroprusside, IABP
Diuretics
Emergent surgery for mitral valve repair (if no papillary muscle
necroses) or replacement

Ventricular Septal Rupture

Occurs equally in anterior and inferior MI :

- Anterior MI : rupture usually in apical septum

- Inferior MI : usually at the base of the heart
- Usually occurs within 3-5 days after MI (sometimes
in first 24 hours)
Risk factor :
- Wrap around LAD (ST elevation in anterior and
inferior leads)
- Large infarct
- RV infarction

 Present with :

1. Sudden onset of hypotension

2. Biventricular failure (mostly right sided due to left to right shunt)
3. New harsh holosystolic murmur
Diagnosed by :
1. Doppler echo
2. Right heart cath showing left to right shunt through septum
Management :
Afterload reduction (Nitroprusside, IABP)
Diuretics
Inotropes (if cardiogenic shock +)
Surgery repair : Surgery is urgent if shock present but can be delayed
for weeks untill infarct heals if patient stable enough

LV Free Wall Rupture

Present in up to 26% of patient who died with AMI
Occurs within 5 days in 50% cases and within 2 weeks in 90%

cases
Risk factors for rupture :
Fibrinolytic therapy (higher incidence than PCI)
No history of angina or previous MI (less collateral circulation)
ST elevation or Q waves on initial ECG
Large infarcts, higher biomarkers
Anterior MI
Age > 70
Female

 Complete rupture or Incomplete / subacute rupture

Diagnosed by : echocardiogram, pericardiocentesis if fluid

present, emergency surgery if fluid is blood

Management :
Fluids, Inotropes, Vassopressor
IABP
Surgical repair

Ventricular Aneurysm
Occurs in 8-15% of MI
Diagnose :
o Often prolonged ST elevation following anterior wall

MI
o Cardiac enlargement and dyskinetic area on echo
o 3rd and 4th heart sounds, systolic murmur and mitral
regurgitation

 Complication with LV aneurysm :

o Heart failure bulging of aneurysm during systole steals parts of

stroke volume so CO and volume load

o Ventricular arrythmias
o Thromboembolism
o Ventricular rupture
Management :
Afterload reduction (usually with ACEI)
Anti ischaemic medication for angina
Anticoagulation
Surgical aneurismectomy

Thromboembolism
Mural thrombi at the site of infarction (especially

large anterior MI)

In atria during atrial fibrillation
Treatment :
ANTICOAGULANT

Cardiac Tamponade
Occur due to rupture at the site of infarction
Present with : hypotension, JVD, muffled heart sound
Treatment :
Pericardiocentesis
Surgery if blood in pericardium

Acute Right to Left Shunt Through Patent

Foramen Ovale
Rare complication
Presents : Patients with RVMI shown with hypotension, clear

lung fields, and decreased blood saturation (cyanotic)

Diagnosed by : TEE
Management :
Principle : to optimize the right ventricular function to minimize
shunting
Surgical intervention is required, includes :
1. Coronary artery bypass grafting
2. Closure of atrial septal defect

THANKS FOR ATTENTION